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Michael W. Smith Agency

Revised:

May 06, 2015

Homeowners

 763-535-7293

 

 

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Information

 

Let me know about any special circumstances you have, such as a swimming pool, wood burning stove, credit problems, etc.

 

For Homeowners, Condominium / Townhouse Owners & Renters Insurance Quotes, please complete the form below.

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This is a request for a Minnesota homeowners quote, not a policy application.  Submitting this form does not obligate you to purchase any homeowners or renters insurance products.  Please complete this form as accurately as possible.   Homeowner insurance rates are subject to change.

General Information

Name
Street
City, State ZIP       
County Located
E-mail
Phone
Fax:
Send information by:

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Current Insurance Information

Insurance Company Expiration Date

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Dwelling Information

Occupancy Usage
Type Construction

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Property Coverage Information

Dwelling Amount Contents Other Structures
Deductible Personal Liability Medical Payments

Scheduled Property

Jewelry $ Furs $
Fine Art/Antiques $ Guns $
Silverware $ Golf Equipment $
Musical Instruments $ Cameras $
Computer Equipment $ Stamps/Coins $

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Dwelling Protection

Responding Fire Department Miles to Fire Department Feet to Fire Hydrant
Fire Alarm Fire Sprinkler System Burglar Alarm

Hold "Ctrl" key down to
make multiple selections

Hold "Ctrl" key down to
make multiple selections

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Applicant's Underwriting Information

Date of birth Marital Status Social Security Number
     
Current address if different from dwelling address

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Dwelling Underwriting Information

Date Purchased Year Built Year Heating Updated
 
Year Wiring Updated Year Roof Updated Year Plumbing Updated
Fireplace Woodstove Swimming Pool
Yes No Yes No Yes No
Claims Last 3 Years What Happened & Amount Paid
Yes No

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Additional Comments

 

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Number of hits since August 15, 1998

 

 

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Copyright 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009 Michael W. Smith Agency